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Diagnosis: Female

Back when Zelda Fitzgerald, her skirts wet from diving into public fountains, was accelerating from madcap toward outright madness, a Wharton School economist named George Taylor made the seemingly fey observation that hemlines rose and fell with the stock market, proposing a causal connection between two presumably separate spheres of human enterprise. Fashion, as the now familiar “hemline index” suggested, is socially determined. With prosperity come optimism and tolerance for risk; women are emboldened to show off a more daring length of leg. But what of more empirical, utilitarian domains? Surely doctors hypothesize independently of whatever forces drive style. Take, for example, the diagnosis and treatment of mental illness. Most of us trust psychiatry to remain immune to fads. And it does, doesn’t it?

One of the consistently fascinating and disturbing aspects of “Mad, Bad and Sad: Women and the Mind Doctors” is Lisa Appignanesi’s assiduous tracking of the modishness of what might be mistaken for a sui generis discipline. Of course, as anyone who has visited a psychiatric hospital — or ridden the subway — can attest, crazy is what we call people who refuse to conform to accepted norms of behavior. And the definition of nonconformity must change in step with styles of conforming.

“Mad, Bad and Sad” is, Appignanesi tells her readers, not only “the story of madness, badness and sadness and the ways in which we have understood them over the last 200 years,” but also a survey of the mad, bad and sad themselves, the particular women, including Zelda Fitzgerald, Lucia Joyce, Virginia Woolf and many less famous patients, who suffered “frenzies, possessions, mania, melancholy, nerves, delusions, aberrant acts, dramatic tics, passionate loves and hates, sex, visual and auditory hallucinations, fears, phobias, fantasies, disturbances of sleep, dissociations, communion with spirits and imaginary friends, addictions, self-harm, self-starvation, depression” and so on. Phew. A list like this makes a girl grateful that Freud even bothered to ask what such desperate, deluded creatures might want. No wonder the 19th century couldn’t build enough asylums to house them.

It seems that as soon as society relinquished witchcraft as the crime for which to punish an overtly liberated woman, it settled on madness as the reason to incarcerate her. As Appignanesi observes, “Patients could well find themselves the victims of a doctor’s prejudice about what kind of behavior constituted sanity: this could all too easily work against women who didn’t conform to the time’s norms of sexual behavior or living habits.”

That diagnoses conceived by male doctors would be subject to men’s changeable views of women — romantic, patronizing, idealistic, misogynistic: the choices are limited only by the imagination — comes as no surprise; it’s the meticulous and exhaustive account of these theories offered in “Mad, Bad and Sad” that is sobering. Victorian women who weren’t locked up for falling victim to lypemania (melancholy), monomania, homicidal monomania or “moral insanity” were at risk of neurasthenia, a “mirror image of rebellion” in which their “nervous depletion” was explained as the result of their “incursion into the masculine sphere of intellectual labor,” a strain that constitutions formed for tender sentiment couldn’t be expected to support. And then came hysteria, which “best expresses women’s distress at the clashing demands and no longer tenable restrictions placed on women in the fin de siècle.”

If male doctors conspired to define madness, responding to behaviors that flouted the social conventions of their culture, female patients, in the attempt to understand themselves and their context, and maybe even to create or bolster identity, colluded with those same doctors to satisfy the changing definitions of madness. “Often enough,” Appignanesi notes, “extreme expressions of the culture’s malaise, symptoms and disorders mirrored the time’s order.” Anorexia, she writes, “is usually an illness of plenty not of famine, as depression is one of times of peace and prosperity, not of war.” Having wept, raved, trembled and hallucinated our way into the 21st century, when “the sum of information available in any given minute is larger than it has ever been in history,” we’ve conceived “a condition in which attention is at a deficit.”

Among all the doctors whose diagnoses and treatments have proved provocative, none have enjoyed the tenaciously divisive stature of Sigmund Freud. Appignanesi, who (with John Forrester) documented the early years of the psychoanalytic movement in “Freud’s Women,” examines the new order ushered in by Freud’s delving “with a radical coolness which had no truck with conventional morality” into “something mysterious and perhaps threatening, constantly in need of investigation, attention or control.”

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That “something” was, of course, sex. To her credit, Appignanesi herself assesses Freud with a kind of radical coolness. She neither monumentalizes his influence nor engages in a perfunctory, reflexive attack on his pioneering work. Instead she tidily summarizes how Freud, having lifted the lid of consciousness off the tenebrous realm of unconscious desires, hostilities, conflicts and Oedipal struggles, begat countless intellectual heirs — his child and analysand Anna Freud, as well as Melanie Klein, Karen Horney and others — who leapt into the postwar baby boom and focused on women “in relation to their biological destiny — menstruation, pregnancy, menopause.” These female pioneers ushered in a cult of childhood and its inevitable corollary, the demonization of mothers, at whose feet piled up responsibilities for all manner of diseases and dysfunctions, from stuttering to schizophrenia, now understood to be neurochemical and decidedly outside the influence of fads.

While “Mad, Bad and Sad” echoes and enlarges upon Elaine Showalter’s book “The Female Malady: Women, Madness, and English Culture, 1830-1980,” Showalter’s perspective is more exclusively feminist, arguing that psychiatry as practiced on women is a history of their subjugation and control by men. But as Appignanesi makes clear, women have had no little role in creating and fulfilling the definitions of their madness. The spreading and treatment-resistant phenomena of anorexia and bulimia are owned largely by women, who account for some 90 percent of patients with eating disorders and who are counseled and treated by an industry of specialists whose attempts to raise consciousness about these diseases have helped also to spread them, in much the same way that neurasthenia so captured the Victorian imagination.

It would be hard to imagine a mental illness that better evinces the slippery interplay among fashion, delusion, diagnosis and treatment than anorexia, which announces itself with the appearance of following rather than defying social directives and which women embrace, as they did neurasthenia, as a mode of femininity, in this case to be slim rather than morbidly sensitive and enervated. Only after the obsessive pursuit of emaciation betrays a subversive refusal to play by the rules of normality does anorexia reveal itself as flagrantly unstylish, an indictment of the very norms it pretended to satisfy. “Anorectics perennially sabotage therapy,” Appignanesi writes, because it isn’t only food they refuse but “any form of intrusion,” even — perhaps especially — that of a mind doctor intent on curing them.

MAD, BAD AND SAD

Women and the Mind Doctors.

By Lisa Appignanesi.

535 pp. W. W. Norton & Company. $29.95.

Kathryn Harrison’s “While They Slept: An Inquiry Into the Murder of a Family” will be published in June.

A version of this review appears in print on , on Page BR13 of the Sunday Book Review with the headline: Diagnosis: Female. Today's Paper|Subscribe